Anorexia and Munchausen Syndrome by Proxy

It is well known that most anorexic girls have over-controlling parents who find it impossible to not be involved in every aspect of the girl’s life. However another aspect has recently come the attention of psychologists and that is the parent with Munchausen syndrome by proxy (MSP) in which one or more of the parents are keeping the child in a state of mental anguish so that the mental state of anorexia continues. This enables the parent to enjoy the drama of hospital life and expanding control to all aspects of medical treatment. It is the very drama of hospitals that is the excitement and fulfillment of the desire to be a hero.

Introduction:

Baron Munchausen was German soldier (1871) who as an officer in the Army regaled all who would listen to his fantastic stories of heroism and adventure. However all was make-believe but enabled him to garner so much attention that his otherwise dull life would offer. In psychological terms we have adapted the term to a syndrome in which one person deliberately exaggerates, fabricates and enhances the mental or physical state of someone in their care. In the case of anorexia this means continuing to create situations and behavior that cause the child/girl to continue in unhealthy thinking, emotion and behavior.

Anorexia Nervosa itself is recognized as a slimming disease in which the girl deliberately refuses nourishment and maintains levels of exercise in order to reduce her weight. This leads to a training of the stomach to accept less food than it requires keeping a healthy balance over height to weight ratios (BMI). In addition the girl acquires rituals (obsessive compulsive behavior) that enable her to reduce the anxiety of feeling over-weight when in fact she is wasting away (body morphism). This may include jerking movements, over-stretching and fast paced walking.

The title – by proxy – means that while the parent in everyday life has a routine, maybe even a dull existence they find that through their children they can create situations is which the child is kept in a sickly state needing hospitalization in order to enjoy the drama of watching the doctors try to save their child, often the over controlling in the family – then extends to the doctors – many of whom are over-whelmed by the parent who is acting as the hero trying to save their child. The Munchausen parent often has read many medical books and particularly about the topic that their child has developed. Therefore often telling the doctors how they should treat their child moment by moment. This causes much pressure and stress to the doctors who now fear law-suits and complaints by the parents who think they know better. Despite what you may see on television most doctors are employees just like any other and have the same fears of unemployment and loss of reputation.

Problems:

Once the Munchausen parent is in control of the doctors, child/girl, and any other professionals they then lose faith in the medical profession to help and so bitterly complain to the same doctors who earlier were considered the most caring considerate doctors – but once the doctors try to take back control – the parents start to look for so-called outside experts – a procession of doctors start visiting the child in hospital (often with no permission from the hospital authorities) brought in as visitors. These so-called famous experts – see the child and reconfirm she is ill – which no one disputed in the first place. However once these outside doctors realize they are being used they soon disappear back to where ever they came from. The parents then start hospital hopping – taking the child to different hospitals on a regular basis – each hospital is better than the last one – each set of doctors more caring – however in time this starts to falter and the new set of doctors realize the situation and wish to distance themselves from the parents.

Although in most cases it is one parent causing the situation the other spouse often is in a supporting role and weaker. They tend to back up the first parent – it is like when you are child and your mother cries, “listen to your father dear”. The second parents often have some psychological problems of their own that they model down to the children in the family. In child development, socialization takes place in the home often by modeling parental behavior – if you father does it will seem normal – therefore the child develops a similar internal belief system, for example if the one parents suffers from anxiety and uses rituals to reduce the emotions then we should not be surprised to see the child imitate that method for themselves.

Psychological Treatment

Although ideally family therapy would be a preferred route with at least two psychologists working together (one as observer) it is not often accepted by the parents as that would mean risking exposure of their motivation for their daughter’s illness. Often the parents will control the issues discussed and pre-brief the therapist as to what they should ask, the focus of attention being the child and making certain subjects taboo. This ensures they still continue to be in control of the situation and the therapist if untrained in clinical work will not understand, often end up confused as to how they became the tool of the parent. Unfortunately most counselors are not trained to deal with difficult cases – and may in fact do more harm than good in becoming manipulated by the parent without realizing it. They in fact may help to increase the anxiety and eating disorder in the child by not tackling the parental problems in the first place. Of course in all this there is a victim – the child – who with the right support and cognitive emotive approach could recover and lead a normal life. The parents while acting as heroes to save the day – in fact continue to evoke behavior in the child by over-control and high criticism. Separation of the child from the parents is the most desirable outcome but immensely difficult as they have created an over-dependency in the child who is confused over the inconsistency of her parents treatment, over-involvement with the doctors and insistence they it is all her own fault, until such a point that the child has lost all trust in the parents and doctors and that they are torn by dependency which is so painful.

Legal obligations:

This is a particular mine field most doctors do not like to tread. If you suspect that a parent is deliberately continuing the child’s suffering in order to enjoy the drama of the situation you are obliged to inform social services as to the situation. However in the case on Munchausen syndrome by proxy it is very difficult to prove in a court – the parent’s behavior judged by most lay people (juries) may be seen as over-protective caring but not as deliberate harm. The child cannot support your case as with most minors they have a dependency problem of not accepting the parents who say she loves you would then harm you on purpose. In Britain where physical harm was often taking place – secret cameras were installed by court order in suspected cases. Often the cameras caught MSP parents suffocating, braking arms and even beating children (babies in most cases) in order to continue the drama. These parents were obviously prosecuted on the evidence of the video shown in court. However in psychological harm it is much more difficult to prove your case. Verbal cruelty and control is not directly a criminal situation that can be witnessed, but only surmised by the anorexic child’s reports of parental coercion. Therefore it is rare or impossible to risk a doctor’s career in court by trying a case as an expert witness to something that may end up blowing back in your face as a counter-complaint of incompetence.

Alternative Strategies:

As soon as the doctors realize the child’s anorexia is in fact being deliberately continued by the parent who is MSP then they fall back on the – sorry we cannot help – sorry we cannot take responsibility – sorry we are not equipped for you daughters case. In other words – they pass the child on. Each hospital in turn realizes the situation within a few weeks and starts to discuss behind close doors discharging the child for lack of progress. However at some point the parents run out of options as now most of the hospitals know who they are. So even at registration – the names are already flagged for rejection. Although this sounds unethical the hospital has an obligation to protect its other patients and not have doctors distracted by over controlling parents who take up considerable time at the hospital – often staying overnight and all day – just to make sure – their child is getting constant attention. This is a dilemma for any hospital that has to offer a level of service that is constant over time and priority of patient care.

Summery:

For the treating psychologist this is a constant challenge. On one hand they have to take into account their ethical obligation to the child’s welfare, that what ever the parent’s problems the child is still in need of care. In order to do this trust with the child is uppermost in the psychologists mind. This may mean taking sides against the other doctors, parents and well-meaning outsiders. What the child needs is consistency of care – that at least one person is always there for them to listen, discuss and help. A child is not an adult patient and often looks to the psychologist for direction and advice. Coming into conflict with the over controlling parents is inevitable as they try to manipulate the psychologist to follow their agenda. The parents often quote – experts at you – telling you that they know best and that you are not doing what they expect of you. Treatment takes a long time – several weeks – many sessions – but the parents want instant results – and if you cannot provide them – you are not good enough and so they are hunting for the next famous expert to take your place. However even for the parents if you are a good therapist with experience the trust you gain with the child can overcome parental interference. The child will often insist on seeing you – as the only person they can really trust – the parents are furious at this outcome as this may mean the child getting more in control and not needing them so much.

Conclusion:

I would like to state there is an easy outcome to this type of case but there is not. It is one reason child separation from the parents is the ideal – get her alone for a while and build up her self confidence to the point she can resist her MSP parent from harming her psychologically. However in most cases this will never happen – so you have to have a high tolerance level for criticism, resistance to being controlled and insightful often novel ways of dealing with the anorexia and MSP at the same time. Your priority should always be the child. However let us not forget that you may have two parents suffering from a mental disorder all of their own – and should be encouraged to seek therapy for themselves. It is best for them to go to individual sessions and not as a family – as the dynamic is already toxic. If the parents can be treated for MSP and other complications the child may have the chance of a future.